Asian Cardiovasc Thorac Ann 2001;9:76-77
© 2001 Asia Publishing EXchange Pte Ltd
Necrotizing Fasciitis of Thoracic Wall Complicating Chest Tube Drainage
Jorge Freixinet, MD,
Pedro Rodríguez, MD,
Norberto Santana, MD,
Mohamed Hussein, MD,
Francisco Cruz, MD,
Felipe Rodríguez de Castro, MD,1
Department of Thoracic Surgery
1 Department of Respiratory Medicine Investigation Unit Hospital de Gran Canaria Dr. Negrín Canary Islands, Spain
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For reprint information contact: Jorge Freixinet, MD Tel: 34 928 45 0647 Fax: 34 928 44 9100 email: jfreixi{at}correo.hpino.rcanaria.es Department of Thoracic Surgery, Hospital de Gran Canaria Dr. Negrín, Barranco de la Ballena s/n, Las Palmas GC 35020, Canary Islands, Spain.
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Abstract
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A 24-year-old man with Werdnig-Hoffman disease developed necrotizing fasciitis caused by Streptococcus milleri complicating treatment of empyema with a chest tube. Extensive debridement was performed repeatedly, but he died 18 days after admission.
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Introduction
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Necrotizing fasciitis (NF) has been described sporadically. It is generally a highly lethal infection and its severity is determined by its capacity to destroy muscle and soft tissue.1 Group-A beta-hemolytic streptococcal NF, popularized as the "flesh-eating infection", has gained great notoriety. Although it can occur in any region of the body, the abdominal wall, perineum, and extremities are the most common sites of infection. Localization in the chest is rare, although descending necrotizing mediastinitis from a cervical infection is now regularly reported. The disease is more likely to occur in patients with a compromised immune system (diabetics, alcoholics, immunosuppressed patients), in drug users, and in patients with peripheral vascular disease, although it can also occur in young, previously healthy individuals.2
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Case Report
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A 24-year-old man with a history of Werdnig-Hoffman disease was admitted to hospital when his disease had progressed to a state of general muscular atrophy. Three weeks prior to admission, he began to experience pharyngeal discomfort, cough, a whitish-yellow sputum, dyspnea, and a slight fever. He was treated with antibiotics, but the symptoms did not respond. Physical examination revealed serious scoliosis, significant thoracic deformity, and a weak vesicular murmur in the right hemithorax. There were no signs of infection within the soft tissue. His hemoglobin level was 107 g•L–1 with a hematocrit of 31.5%. Arterial blood gas analysis showed respiratory acidosis. Chest radiography indicated condensation and pleural effusion in the right lung. A drainage tube was placed in the pleural cavity and purulent liquid was drained. A pleural fluid culture yielded Streptococcus milleri sensitive to penicillin G and gentamicin. Blood cultures were negative and fibrobronchoscopy was normal. After 3 days, erythema appeared around the insertion point of the drainage tube. Computed tomography at this time revealed marked asymmetry of both hemithoraces with general muscular atrophy, enlargement of the soft part of the right thoracic wall with air that extended up to the last rib, a right hydropneumothorax, severe shrinkage of the right side of the chest, and multiple bronchiectasis in the right lower lobe (Figure 1
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Figure 1. Chest computed tomography showing enlargement of the soft parts of the right hemithorax, right hydropneumothorax, severe shrinkage and multiple bronchiectasis in the lower right lobe.
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The soft part of the thoracic wall became progressively worse, as evidenced by cutaneous and fat necrosis. The right hemithoracic wall was surgically cleaned and this verified significant NF. Extensive debridement was repeated 5 times to control the muscular infection. Open thoracostomy was also performed because the lung could not expand and the pleural chamber was insufficiently drained. The patient needed a transfusion of 3 units of red blood cell concentrate, due to severe anemia. His general health worsened rapidly. He suffered episodes of hypotension, oliguria, bed sores, hyponatremia, and hypo-proteinemia. He died 18 days after admission.
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Discussion
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In 1924, Meleny3 described gaseous gangrene of the skin due to an infection in the subcutaneous tissue caused by hemolytic streptococcus. The term "necrotizing fasciitis" was introduced by Wilson4 in 1952 to define a soft tissue infection with fat and muscular necrosis, and with a tendency to expand and generalize. NF of the chest wall is very rare. In a recent review, only 9 cases had been found in the English-language medical literature, and it seemed to be due largely to complications of pleural drainage and excessive soft tissue dissection during chest tube insertion.1 Other causes have been described, in-cluding spontaneous appearance.
In 90% of cases, there is already a serious basic systemic illness that compromises the immune system and plays an important role in predisposing toward this infection. Our case involved the final stage of a congenital neuromuscular disease (with no evidence of immunodeficiency). NF was the result of placing a pleural drainage tube to resolve empyema caused by Streptococcus milleri. Streptococcus milleri is a specie of hemolytic microaerophilic Strepto-coccus viridans, which differs from the others in its particular tendency to cause visceral abscesses and cavities with infected liquid. It can reach the lungs in different ways but pleural empyema has been described frequently.5 Streptococcus milleri is sensitive to penicillin and amino-glycoside; such antibiotics were used in this patient. In none of the 9 cases described previously was Streptococcus milleri found.1
The first manifestations of NF include pain, edema, and reddening of the skin; an appearance similar to superficial cellulitis. However, NF progresses rapidly to a general septic appearance and spreads extensively through muscle and subcutaneous cellular tissue. NF may be lethal not only because of its severity, but also because of the problems in diagnosing it during the early stages. Due to the paucity of skin findings early in the disease, diagnosis is often extremely difficult and relies on a high index of suspicion. The role of computed tomography in detecting soft tissue gas is essential. It is also important as a guide to further treatment after initial surgical debridement. Treatment modalities include early and adequate surgical debridement and fasciotomy, broad aerobic and anaerobic antibiotic coverage, and supportive care. Delays in diagnosis or treatment correlate with poor outcome, with the cause of death being overwhelming sepsis syndrome or multiorgan failure.1,6 Treatment with hyperbaric oxygen has been described for NF in general but not for NF of the thorax. The only survivor in the reported cases suffered severe defects in the thoracic wall as a consequence of the debridement, and required ventilation for approximately 2 months.7
NF of the chest wall has a high mortality rate, 89% in a recently published collective review.1 This is not only due to its aggressiveness, but also to the initial illness. In this case, the illness was discovered in such an advanced state that the patient had already reached the final phase even before the appearance of NF.
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References
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Urschel JD, Takita H, Antkowiak JG. Necrotizing soft tissue infections of the chest wall. Ann Thorac Surg 1997; 64:276–9.[Abstract/Free Full Text]
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Molina JM, Leport C, Bure A, Wolff M, Michon C, Vilde JL. Clinical and bacterial features of infections caused by Streptococcus milleri. Scand J Infect Dis 1991;23: 659–66.[Medline]
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Meleny FL. Haemolytic streptococcal gangrene. Arch Surg 1924;9:317–64.[Abstract/Free Full Text]
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Wilson B. Necrotizing fasciitis. Am J Surg 1952;18: 416–31.
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Hocken DB, Dussek JE. Streptococcus milleri as a cause of pleural empyema. Thorax 1985;40:626–8.[Abstract/Free Full Text]
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Chen YM, Wu MF, Lee PY, Su WJ, Perng RP. Necrotizing fasciitis: is it a fatal complication of tube thoracostomy? Report of three cases. Respir Med 1992;86:249–51.[Medline]
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LoCicero J III, Vanecko RM. Clostridial myonecrosis of the chest wall complicating spontaneous esophageal rupture. Ann Thorac Surg 1985;40:396–7.[Abstract]
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Abstract
Introduction
